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Akabane M, Melcher ML, Esquivel CO, Imaoka Y, Kim WR, Sasaki K. Enhancing the usability of older DCD donors through strategic approaches in liver transplantation in the United States. Liver Transpl 2024:01445473-990000000-00361. [PMID: 38625836 DOI: 10.1097/lvt.0000000000000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/17/2024] [Indexed: 04/18/2024]
Abstract
The use of older donors after circulatory death (DCD) for liver transplantation (LT) has increased over the past decade. This study examined whether outcomes of LT using older DCD (≥50 y) have improved with advancements in surgical/perioperative care and normothermic machine perfusion (NMP) technology. A total of 7602 DCD LT cases from the United Network for Organ Sharing database (2003-2022) were reviewed. The impact of older DCD donors on graft survival was assessed using the Kaplan-Meier and HR analyses. In all, 1447 LT cases (19.0%) involved older DCD donors. Although there was a decrease in their use from 2003 to 2014, a resurgence was noted after 2015 and reached 21.9% of all LTs in the last 4 years (2019-2022). Initially, 90-day and 1-year graft survivals for older DCDs were worse than younger DCDs, but this difference decreased over time and there was no statistical difference after 2015. Similarly, HRs for graft loss in older DCD have recently become insignificant. In older DCD LT, NMP usage has increased recently, especially in cases with extended donor-recipient distances, while the median time from asystole to aortic cross-clamp has decreased. Multivariable Cox regression analyses revealed that in the early phase, asystole to cross-clamp time had the highest HR for graft loss in older DCD LT without NMP, while in the later phases, the cold ischemic time (>5.5 h) was a significant predictor. LT outcomes using older DCD donors have become comparable to those from young DCD donors, with recent HRs for graft loss becoming insignificant. The strategic approach in the recent period could mitigate risks, including managing cold ischemic time (≤5.5 h), reducing asystole to cross-clamp time, and adopting NMP for longer distances. Optimal use of older DCD donors may alleviate the donor shortage.
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Affiliation(s)
- Miho Akabane
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - Marc L Melcher
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - Carlos O Esquivel
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - Yuki Imaoka
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California, USA
| | - Kazunari Sasaki
- Department of Surgery, Division of Abdominal Transplant, Stanford University Medical Center, Stanford, California, USA
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2
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Kim SC, Foley DP. Strategies to Improve the Utilization and Function of DCD Livers. Transplantation 2024; 108:625-633. [PMID: 37496117 DOI: 10.1097/tp.0000000000004739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Despite the increased usage of livers from donation after circulatory death (DCD) donors in the last decade, many patients remaining on the waitlist who need a liver transplant. Recent efforts have focused on maximizing the utilization and outcomes of these allografts using advances in machine perfusion technology and other perioperative strategies such as normothermic regional perfusion (NRP). In addition to the standard donor and recipient matching that is required with DCD donation, new data regarding the impact of graft steatosis, extensive European experience with NRP, and the increasing use of normothermic and hypothermic machine perfusion have shown immense potential in increasing DCD organ overall utilization and improved outcomes. These techniques, along with viability testing of extended criteria donors, have generated early promising data to consider the use of higher-risk donor organs and more widespread adoption of these techniques in the United States. This review explores the most recent international literature regarding strategies to optimize the utilization and outcomes of DCD liver allografts, including donor-recipient matching, perioperative strategies including NRP versus rapid controlled DCD recovery, viability assessment of discarded livers, and postoperative strategies including machine perfusion versus pharmacologic interventions.
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Affiliation(s)
- Steven C Kim
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - David P Foley
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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3
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Shen T, Zheng SH, Chen J, Zhou ZS, Yang MF, Liu XY, Chen JL, Zheng SS, Xu X. Older liver grafts from donation after circulatory death are associated with impaired survival and higher incidence of biliary non-anastomotic stricture. Hepatobiliary Pancreat Dis Int 2023; 22:577-583. [PMID: 36775686 DOI: 10.1016/j.hbpd.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 12/29/2022] [Indexed: 02/14/2023]
Abstract
BACKGROUND Grafts from older donors after circulatory death were associated with inferior outcome in liver transplants in the past. But it has seemed to remain controversial in the last decade, as a result of modified clinical protocols, selected recipients, and advanced technology of organ perfusion and preservation. The present study aimed to examine the impact of older donor age on complications and survival of liver transplant using grafts from donation after circulatory death (DCD). METHODS A total of 944 patients who received DCD liver transplantation from 2015 to 2020 were included and divided into two groups: using graft from older donor (aged ≥ 65 years, n = 87) and younger donor (age < 65 years, n = 857). Propensity score matching (PSM) was applied to eliminate selection bias. RESULTS A progressively increased proportion of liver transplants with grafts from older donors was observed from 1.68% to 15.44% during the study period. The well-balanced older donor (n = 79) and younger donor (n = 79) were 1:1 matched. There were significantly more episodes of biliary non-anastomotic stricture (NAS) in the older donor group than the younger donor group [15/79 (19.0%) vs. 6/79 (7.6%); P = 0.017]. The difference did not reach statistical significance regarding early allograft dysfunction (EAD) and primary non-function (PNF). Older livers had a trend toward inferior 1-, 2-, 3-year graft and overall survival compared with younger livers, but these differences were not statistically significant (63.1%, 57.6%, 57.6% vs. 76.9%, 70.2%, 67.7%, P = 0.112; 64.4%, 58.6%, 58.6% vs. 76.9%, 72.2%, 72.2%, P = 0.064). The only risk factor for poor survival was ABO incompatible transplant (P = 0.008) in the older donor group. In the subgroup of ABO incompatible cases, it demonstrated a significant difference in the rate of NAS between the older donor group and the younger donor group [6/8 (75.0%) vs. 3/14 (21.4%); P = 0.014]. CONCLUSIONS Transplants with grafts from older donors (aged ≥ 65 years) after circulatory death are more frequently associated with inferior outcome compared to those from younger donors. Older grafts from DCD are more likely to develop NAS, especially in ABO incompatible cases.
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Affiliation(s)
- Tian Shen
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310022, China
| | - Shan-Hua Zheng
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jun Chen
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | | | - Meng-Fan Yang
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Xiang-Yan Liu
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310022, China
| | - Jun-Li Chen
- China Liver Transplant Registry, Hangzhou 310003, China
| | - Shu-Sen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Hangzhou 310022, China; Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China; Institute of Organ Transplantation, Zhejiang University, Hangzhou 310003, China
| | - Xiao Xu
- Key Laboratory of Integrated Oncology and Intelligent Medicine of Zhejiang Province, Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China; NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China; Institute of Organ Transplantation, Zhejiang University, Hangzhou 310003, China.
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4
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Incidence of Ischemia Reperfusion Injury Related Biliary Complications in Liver Transplantation: Effect of Different Types of Donors. Transplant Proc 2022; 54:1865-1873. [DOI: 10.1016/j.transproceed.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 04/07/2022] [Accepted: 05/02/2022] [Indexed: 11/19/2022]
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5
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Honarmand K, Alshamsi F, Foroutan F, Rochwerg B, Belley-Cote E, Mclure G, D'Aragon F, Ball IM, Sener A, Selzner M, Guyatt G, Meade MO. Antemortem Heparin in Organ Donation After Circulatory Death Determination: A Systematic Review of the Literature. Transplantation 2021; 105:e337-e346. [PMID: 33901108 DOI: 10.1097/tp.0000000000003793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Donation after circulatory death determination frequently involves antemortem heparin administration to mitigate peri-arrest microvascular thrombosis. We systematically reviewed the literature to: (1) describe heparin administration practices and (2) explore the effects on transplant outcomes. We searched MEDLINE and EMBASE for studies reporting donation after circulatory death determination heparin practices including use, dosage, and timing (objective 1). To explore associations between antemortem heparin and transplant outcomes (objective 2), we (1) summarized within-study comparisons and (2) used meta-regression analyses to examine associations between proportions of donors that received heparin and transplant outcomes. We assessed risk of bias using the Newcastle Ottawa Scale and applied the GRADE methodology to determine certainty in the evidence. For objective 1, among 55 eligible studies, 48 reported heparin administration to at least some donors (range: 15.8%-100%) at variable doses (up to 1000 units/kg) and times relative to withdrawal of life-sustaining therapy. For objective 2, 7 studies that directly compared liver transplants with and without antemortem heparin reported lower rates of primary nonfunction, hepatic artery thrombosis, graft failure at 5 y, or recipient mortality (low certainty of evidence). In contrast, meta-regression analysis of 32 liver transplant studies detected no associations between the proportion of donors that received heparin and rates of early allograft dysfunction, primary nonfunction, hepatic artery thrombosis, biliary ischemia, graft failure, retransplantation, or patient survival (very low certainty of evidence). In conclusion, antemortem heparin practices vary substantially with an uncertain effect on transplant outcomes. Given the controversies surrounding antemortem heparin, clinical trials may be warranted.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Farid Foroutan
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Center, University Health Network, Toronto, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Cote
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Graham Mclure
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Frederick D'Aragon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ian M Ball
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Alp Sener
- Department of Surgery and Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Markus Selzner
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Maureen O Meade
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
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6
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Ruiz P, Valdivieso A, Palomares I, Prieto M, Ventoso A, Salvador P, Senosiain M, Fernandez JR, Testillano M, Bustamante FJ, Gastaca M. Similar Results in Liver Transplantation From Controlled Donation After Circulatory Death Donors With Normothermic Regional Perfusion and Donation After Brain Death Donors: A Case-Matched Single-Center Study. Liver Transpl 2021; 27:1747-1757. [PMID: 34455694 DOI: 10.1002/lt.26281] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/01/2021] [Accepted: 08/21/2021] [Indexed: 12/13/2022]
Abstract
Although good results have been reported with the use of normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) liver transplantation (LT), there is a lack of evidence to demonstrate similar results to donation after brain death (DBD). We present a single-center retrospective case-matched (1:2) study including 100 NRP cDCD LTs and 200 DBD LTs and a median follow-up of 36 months. Matching was done according to donor age, recipient Model for End-Stage Liver Disease score, and cold ischemia time. The following perioperative results were similar in both groups: alanine transaminase peaks of 909 U/L in the DBD group and 836 U/L in the cDCD group and early allograft disfunction percentages of 21% and 19.2%, respectively. The 1-year and 3-year overall graft survival for cDCD was 99% and 93%, respectively, versus 92% and 87%, respectively, for DBD (P = 0.04). Of note, no cases of primary nonfunction or ischemic-type biliary lesion were observed among the cDCD grafts. Our results confirm that NRP cDCD LT meets the same outcomes as those obtained with DBD LT and provides evidence to support the idea that cDCD donors per se should no longer be considered as "marginal donors" when recovered with NRP.
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Affiliation(s)
- Patricia Ruiz
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
| | - Andres Valdivieso
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
| | - Ibone Palomares
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
| | - Mikel Prieto
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
| | - Alberto Ventoso
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
| | - Patricia Salvador
- Hepatology and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Basque Country, Barakaldo, Spain
| | - Maria Senosiain
- Hepatology and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Basque Country, Barakaldo, Spain
| | - Jose Ramon Fernandez
- Hepatology and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Basque Country, Barakaldo, Spain
| | - Milagros Testillano
- Hepatology and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Basque Country, Barakaldo, Spain
| | - Francisco Javier Bustamante
- Hepatology and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Basque Country, Barakaldo, Spain
| | - Mikel Gastaca
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, BioCruces Health Research Institute, University of the Bask Country, Barakaldo, Spain
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7
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Schlegel A, Foley DP, Savier E, Flores Carvalho M, De Carlis L, Heaton N, Taner CB. Recommendations for Donor and Recipient Selection and Risk Prediction: Working Group Report From the ILTS Consensus Conference in DCD Liver Transplantation. Transplantation 2021; 105:1892-1903. [PMID: 34416750 DOI: 10.1097/tp.0000000000003825] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Although the utilization of donation after circulatory death donors (DCDs) for liver transplantation (LT) has increased steadily, much controversy remains, and no common acceptance criteria exist with regard to donor and recipient risk factors and prediction models. A consensus conference was organized by International Liver Transplantation Society on January 31, 2020, in Venice, Italy, to review the current clinical practice worldwide regarding DCD-LT and to develop internationally accepted guidelines. The format of the conference was based on the grade system. International experts in this field were allocated to 6 working groups and prepared evidence-based recommendations to answer-specific questions considering the currently available literature. Working group members and conference attendees served as jury to edit and confirm the final recommendations presented at the end of the conference by each working group separately. This report presents the final statements and recommendations provided by working group 2, covering the entire spectrum of donor and recipient risk factors and prediction models in DCD-LT.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, Florence, Italy
| | - David P Foley
- University of Wisconsin School of Medicine and Public Health, William S. Middleton VA Medical Center, Madison, WI
| | - Eric Savier
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne Université Pitié-Salpêtrière Hospital, Paris, France
| | - Mauricio Flores Carvalho
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, Florence, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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8
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Early Allograft Dysfunction and Complications in DCD Liver Transplantation: Expert Consensus Statements From the International Liver Transplantation Society. Transplantation 2021; 105:1643-1652. [PMID: 34291765 DOI: 10.1097/tp.0000000000003877] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Livers for transplantation from donation after circulatory death donors are relatively more prone to early and ongoing alterations in graft function that might ultimately lead to graft loss and even patient death. In consideration of this fact, this working group of the International Liver Transplantation Society has performed a critical evaluation of the medical literature to create a set of statements regarding the assessment of early allograft function/dysfunction and complications arising in the setting of donation after circulatory death liver transplantation.
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9
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Wang W, Liu Z, Qian J, Xu J, Que S, Zhuang L, Geng L, Zhou L, Zheng S. Systematic Assessment of Safety Threshold for Donor Age in Cadaveric Liver Transplantation. Front Med (Lausanne) 2021; 8:596552. [PMID: 33748155 PMCID: PMC7969668 DOI: 10.3389/fmed.2021.596552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/08/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Donor age affects allograft quality and the prognosis of recipients after liver transplantation (LT). Clinicians have assessed the quality of grafts from older donors based on their appearance and texture, with no reliable quantitative evidence. Our study aimed to assess the quantitative impact of donor age on post-transplant outcomes and its safety threshold for LT, based on the published literature. Methods: Relevant studies were retrieved from the Embase, PubMed, and ISI Web of Science databases. Pooled dichotomous relative risks (RRs) were calculated using metan. Continuous RRs were calculated using a two-stage random-effects model. Results: Eleven studies including 30,691 LT cases were included for further analysis. For categorical comparison, the RR of death within the first post-transplant year was significantly higher among patients who received grafts from older donors. Similarly, the RR of graft failure (GF) was increased within the 3 years after transplantation. For continuous comparison, advanced donor age affected transplant outcomes in a linear manner (P > 0.05). A 10-year increment in donor age was associated with RRs 1.10, 1.12, 1.15, 1.10, and 1.08 for 90-day, 180-day, 1-year, 3-year, and 5-year patient mortality and 1.08, 1.06, 1.10, 1.11, and 1.12, for 90-day, 180-day, 1-year, 2-year, and 3-year GF, respectively (all P < 0.05). A spline model showed that transplants using grafts from donors <43 years old were not associated with age-related risks (P > 0.05). The risk of GF was increased in subgroups with fewer LT cases, longer cold ischemic time, fewer male donors, and recipients with viral hepatitis (P < 0.05). Conclusion: Donor age might affect post-LT outcomes in a dose-dependent manner. The safety threshold for donor age in terms of GF should be lowered to 43 years as an early warning for the guarantee of satisfactory outcomes. Clinicians should weigh the benefits against the risks carefully for patients receiving grafts from older donors. Further studies are warranted to investigate the mechanisms responsible for the relationship between donor age and graft quality.
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Affiliation(s)
- Wenchao Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Chinese Academy of Medical Sciences, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhengtao Liu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Chinese Academy of Medical Sciences, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junjie Qian
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Chinese Academy of Medical Sciences, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jun Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuping Que
- Science for Life Laboratory, Kungliga Tekniska Högskolan - Royal Institute of Technology, Stockholm, Sweden.,DingXiang Clinics, Hangzhou, China
| | - Li Zhuang
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Lei Geng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lin Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Chinese Academy of Medical Sciences, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Chinese Academy of Medical Sciences, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
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10
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Tchana-Sato V, Ledoux D, Detry O, Hans G, Ancion A, D'Orio V, Massion PB, Amabili P, Bruls S, Lavigne JP, Monard J, Delbouille MH, Sakalihasan N, Defraigne JO. Successful clinical transplantation of hearts donated after circulatory death using normothermic regional perfusion. J Heart Lung Transplant 2020; 38:593-598. [PMID: 31128600 DOI: 10.1016/j.healun.2019.02.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Heart transplantation (HT) from donation after circulatory death (DCD) has yet to achieve wide clinical application despite the encouraging resultsreported recently. In this study we describe 2 cases of successful adult DCD HT performed at our institution using an original protocol. METHODS Our local abdominal DCD protocol was updated to allow DCD heart procurement, and was accepted by the institutional ethics committee. The main features of the protocol include: pre-mortem insertion of peripheral venoarterial extracorporeal membrane oxygenation cannulas; thoracoabdominal normothermic regional perfusion (NRP) by clamping the 3 aortic arch vessels to exclude cerebral circulation; and in-situ heart resuscitation. The retrieved hearts were directly transplanted into recipients located in an adjoining operating room. RESULTS The procurement warm ischemic time was 25 minutes for the first donor, and 26 minutes for the second donor. The cold ischemic time was 16 minutes for the first recipient and 17 minutes for the second recipient. The suture time was 30 minutes for the first recipient, and 53 minutes for the second recipient. Both recipients were easily weaned off cardiopulmonary bypass in sinus rhythm and inotropic support. Post-operative evaluation of cardiac function was excellent and the patients were subsequently discharged home. CONCLUSIONS Transplantation of hearts from DCD donors is now a clinical reality.NRP is a useful tool for resuscitation, reperfusion, and preservation of transplanted hearts. It also offers the opportunity to assess the function and viability of organs before transplantation. However,due to ethical issues, some may object to ante-mortem intervention.
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Affiliation(s)
| | | | - Olivier Detry
- Abdominal Surgery and Transplantation, Liege, Belgium
| | - Gregory Hans
- Anesthesiology and Intensive Care, Liege, Belgium
| | | | | | | | | | - Samuel Bruls
- Departments ofCardiothoracic Surgery, Liege, Belgium
| | | | - Josée Monard
- Abdominal Surgery and Transplantation, Liege, Belgium
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11
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Zhang Z, Ju W, Tang Y, Wang L, Zhu C, Gao N, Zhao Q, Huang S, Wang D, Yang L, Han M, Xiong W, Wu L, Chen M, Zhang Y, Zhu Y, Sun C, Zhu X, Guo Z, He X. First Preliminary Experience with Preservation of Liver Grafts from Extended-Criteria Donors by Normothermic Machine Perfusion in Asia. Ann Transplant 2020; 25:e921529. [PMID: 32312947 PMCID: PMC7193227 DOI: 10.12659/aot.921529] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/24/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Normothermic machine perfusion (NMP) can provide access to evaluate and resuscitate high-risk donor livers before transplantation. The purpose of this study was to determine the efficacy of NMP in preservation and assessment of extended-criteria donor (ECD) livers in China. CASE REPORT From September 2018 to March 2019, 4 liver grafts from 3 transplant center defined as ECD were subjected to NMP, and then were transplanted successfully. During perfusion, perfusion parameters such as vascular flow, glucose level, lactate clearance, and bile production/composition were recorded to assess graft viability. All recipients were followed up 6 months after transplantation. CONCLUSIONS NMP provides a potential tool for preservation and assessment of ECD livers in China.
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Affiliation(s)
- Zhiheng Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Weiqiang Ju
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Yunhua Tang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Linhe Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Caihui Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Ningxin Gao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Qiang Zhao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Shanzhou Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Dongping Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Lu Yang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Ming Han
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Wei Xiong
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Linwei Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Maogen Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Yixi Zhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Yanling Zhu
- Department of Cardiopulmonary Bypass, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Chengjun Sun
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Xiaofeng Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, P.R. China
- Organ Transplant Center, Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, Guangdong, P.R. China
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12
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Cascales-Campos PA, Ferreras D, Alconchel F, Febrero B, Royo-Villanova M, Martínez M, Rodríguez JM, Fernández-Hernández JÁ, Ríos A, Pons JA, Sánchez-Bueno F, Robles R, Martínez-Barba E, Martínez-Alarcón L, Parrilla P, Ramírez P. Controlled donation after circulatory death up to 80 years for liver transplantation: Pushing the limit again. Am J Transplant 2020; 20:204-212. [PMID: 31329359 DOI: 10.1111/ajt.15537] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/20/2019] [Accepted: 07/09/2019] [Indexed: 01/25/2023]
Abstract
Our main objective was to compare liver transplant (LT) results between donation after circulatory death (DCD) and donation after brainstem death (DBD) in our hospital and to analyze, within the DCD group, the influence of age on the results obtained with DCD donors aged >70 years and up to 80 years. All DCD-LTs performed were analyzed prospectively. The results of the DCD group were compared with those of a control group who received a DBD-LT immediately after each DCD-LT. Later, the results obtained within the DCD group were analyzed according to the age of the donors, considering 2 subgroups with a cut-off point at 70 years. Survival results for LT with DCD and super rapid recovery were not inferior to those obtained in a similar group of patients transplanted with DBD livers. However, the cost of DCD was a higher rate of biliary complications, including ischemic cholangiopathy. Donor age was not a negative factor.
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Affiliation(s)
- Pedro A Cascales-Campos
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - David Ferreras
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Felipe Alconchel
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Beatriz Febrero
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Mario Royo-Villanova
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.,Intensive Care Unit, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - María Martínez
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.,Intensive Care Unit, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - José M Rodríguez
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Juan Á Fernández-Hernández
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Antonio Ríos
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José A Pons
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.,Department of Hepatology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Francisco Sánchez-Bueno
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Ricardo Robles
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Enrique Martínez-Barba
- Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain.,Department of Patholoy, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Laura Martínez-Alarcón
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Pascual Parrilla
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Pablo Ramírez
- Department of Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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13
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Li Y, Ruan DY, Jia CC, Zheng J, Wang GY, Zhao H, Yang Q, Liu W, Yi SH, Li H, Wang GS, Yang Y, Chen GH, Zhang Q. Aging aggravates hepatic ischemia-reperfusion injury in mice by impairing mitophagy with the involvement of the EIF2α-parkin pathway. Aging (Albany NY) 2019; 10:1902-1920. [PMID: 30089704 PMCID: PMC6128434 DOI: 10.18632/aging.101511] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/28/2018] [Indexed: 02/07/2023]
Abstract
Hepatic ischemia-reperfusion (I/R) injury fundamentally influences the performance of aged liver grafts. The significance of mitophagy in the age dependence of sensitivity to I/R injury remains poorly understood. Here, we show that aging aggravated hepatic I/R injury with decreased mitophagy in mice. The enhancement of mitophagy resulted in significant protection against hepatic I/R injury. Parkin, an E3 ubiquitin ligase, was found depleted by I/R in aged livers. In oxygen-glucose deprivation reperfusion (OGD-Rep.)-treated L02 cells, parkin silencing impaired mitophagy and aggravated cell damage through a relative large mitochondrial membrane potential transition. The phosphorylation of the endoplasmic reticulum stress response protein EIF2α, which was also reduced in the aged liver, induced parkin expression both in vivo and vitro. Forty-six hepatic biopsy specimens from liver graft were collected 2 hours after complete revascularization, followed by immunohistochemical analyses. Parkin expression was negatively correlated to donor age and the peak level of aspartate aminotransferase within first week after liver transplantation. Our translational study demonstrates that aging aggravated hepatic I/R injury by impairing the age-dependent mitophagy function via an insufficient parkin expression and identifies a new strategy to evaluate the capacity of an aged liver graft in the process of I/R through the parkin expression.
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Affiliation(s)
- Yang Li
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China.,Guangdong Key laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong 510630, China
| | - Dan-Yun Ruan
- Department of Medical Oncology, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong 510630, China
| | - Chang-Chang Jia
- Department of Biotherapy, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong 510630, China.,Guangdong Key laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong 510630, China
| | - Jun Zheng
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China.,Guangdong Key laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong 510630, China
| | - Guo-Ying Wang
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Hui Zhao
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Qing Yang
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Wei Liu
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China.,Guangdong Key laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong 510630, China
| | - Shu-Hong Yi
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Hua Li
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Gen-Shu Wang
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Yang Yang
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Gui-Hua Chen
- Department of Liver Surgery and Liver Transplantation, Guangzhou Clinical Research and Translation Center for Liver Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Qi Zhang
- Department of Biotherapy, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong 510630, China.,Guangdong Key laboratory of Liver Disease Research, The Third Affiliated Hospital of Sun Yat-sen University, Guangdong 510630, China
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14
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Mihaylov P, Mangus R, Ekser B, Cabrales A, Timsina L, Fridell J, Lacerda M, Ghabril M, Nephew L, Chalasani N, Kubal CA. Expanding the Donor Pool With the Use of Extended Criteria Donation After Circulatory Death Livers. Liver Transpl 2019; 25:1198-1208. [PMID: 30929303 DOI: 10.1002/lt.25462] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/16/2019] [Indexed: 02/07/2023]
Abstract
Use of donation after circulatory death (DCD) donor livers for transplantation has remained cautious in the United States. The aim of this study was to demonstrate the expansion of a DCD liver transplantation (LT) program with the use of extended criteria donor (ECD) DCD livers. After institutional review board approval, 135 consecutive DCD LTs were retrospectively studied. ECD DCD livers were defined as those with 1 of the following factors: donor age >50 years, donor body mass index >35 kg/m2 , donor functional warm ischemia time >30 minutes, and donor liver macrosteatosis >30%. An optimization protocol was introduced in July 2011 to improve outcomes of DCD LT, which included thrombolytic donor flush and efforts to minimize ischemia times. The impact of this protocol on outcomes was evaluated in terms of graft loss, ischemic cholangiopathy (IC), and change in DCD LT volume. Of 135 consecutive DCD LTs, 62 were ECD DCDs. In total, 24 ECD DCD LTs were performed before (era 1) and 38 after the institution of optimization protocol (era 2), accounting for an increase in the use of ECD DCD livers from 39% to 52%. Overall outcomes of ECD DCD LT improved in era 2, with a significantly lower incidence of IC (5% versus 17% in era 1; P = 0.03) and better 1-year graft survival (93% versus 75% in era 1; P = 0.07). Survival outcomes for ECD DCD LT in era 2 were comparable to matched deceased donor LT. With the expansion of the DCD donor pool, the number of DCD LTs performed at our center gradually increased in era 2 to account for >20% of the center's LT volume. In conclusion, with the optimization of perioperative conditions, ECD DCD livers can be successfully transplanted to expand the donor pool for LT.
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Affiliation(s)
- Plamen Mihaylov
- Transplant Division, Indiana University School of Medicine, Indianapolis, IN
| | - Richard Mangus
- Transplant Division, Indiana University School of Medicine, Indianapolis, IN
| | - Burcin Ekser
- Transplant Division, Indiana University School of Medicine, Indianapolis, IN
| | - Arianna Cabrales
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Lava Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Jonathan Fridell
- Transplant Division, Indiana University School of Medicine, Indianapolis, IN
| | - Marco Lacerda
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
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15
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Ghinolfi D, Rreka E, De Tata V, Franzini M, Pezzati D, Fierabracci V, Masini M, Cacciatoinsilla A, Bindi ML, Marselli L, Mazzotti V, Morganti R, Marchetti P, Biancofiore G, Campani D, Paolicchi A, De Simone P. Pilot, Open, Randomized, Prospective Trial for Normothermic Machine Perfusion Evaluation in Liver Transplantation From Older Donors. Liver Transpl 2019; 25:436-449. [PMID: 30362649 DOI: 10.1002/lt.25362] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 10/17/2018] [Indexed: 12/12/2022]
Abstract
Ex situ normothermic machine perfusion (NMP) might minimize ischemia/reperfusion injury (IRI) of liver grafts. In this study, 20 primary liver transplantation recipients of older grafts (≥70 years) were randomized 1:1 to NMP or cold storage (CS) groups. The primary study endpoint was to evaluate graft and patient survival at 6 months posttransplantation. The secondary endpoint was to evaluate liver and bile duct biopsies; IRI by means of peak transaminases within 7 days after surgery; and incidence of biliary complications at month 6. Liver and bile duct biopsies were collected at bench surgery, end of ex situ NMP, and end of transplant surgery. Interleukin (IL) 6, IL10, and tumor necrosis factor α (TNF-α) perfusate concentrations were tested during NMP. All grafts were successfully transplanted. Median (interquartile range) posttransplant aspartate aminotransferase peak was 709 (371-1575) IU/L for NMP and 574 (377-1162) IU/L for CS (P = 0.597). There was 1 hepatic artery thrombosis in the NMP group and 1 death in the CS group. In NMP, we observed high TNF-α perfusate levels, and these were inversely correlated with lactate (P < 0.001). Electron microscopy showed decreased mitochondrial volume density and steatosis and an increased volume density of autophagic vacuoles at the end of transplantation in NMP versus CS patients (P < 0.001). Use of NMP with older liver grafts is associated with histological evidence of reduced IRI, although the clinical benefit remains to be demonstrated.
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Affiliation(s)
- Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa, Pisa, Italy
| | - Erion Rreka
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa, Pisa, Italy
| | - Vincenzo De Tata
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Maria Franzini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Daniele Pezzati
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa, Pisa, Italy
| | - Vanna Fierabracci
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Matilde Masini
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | - Maria Lucia Bindi
- Department of Anesthesia, Medical School Hospital, University of Pisa, Pisa, Italy
| | - Lorella Marselli
- Department of Endocrinology and Metabolism in Organ Transplantation Unit, University of Pisa, Pisa, Italy
| | | | | | - Piero Marchetti
- Department of Endocrinology and Metabolism in Organ Transplantation Unit, University of Pisa, Pisa, Italy
| | | | | | - Aldo Paolicchi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation Unit, University of Pisa, Pisa, Italy
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16
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Vivalda S, Zhengbin H, Xiong Y, Liu Z, Wang Z, Ye Q. Vascular and Biliary Complications Following Deceased Donor Liver Transplantation: A Meta-analysis. Transplant Proc 2019; 51:823-832. [PMID: 30979471 DOI: 10.1016/j.transproceed.2018.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/15/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess biliary and vascular complications after liver transplantations (LTs) sourced from deceased donors. METHODS This study reviewed potentially relevant English-language articles gathered from PubMed and Medline published from 2012 to 2017. One additional study was carried out using our institution's database for articles published from 2013 to 2017. Biliary and vascular complications from adult patients receiving their first deceased-donor LT were included. This meta-analysis was performed using Review Manager version 5.2 (Cochrane Collaboration, Copenhagen, Denmark) and the study quality was evaluated using the Newcastle-Ottawa Scale. RESULTS Ten studies met our inclusion criteria. Heterogeneity in donation after cardiac death (DCD) and donation after brain death (DBD) recipients was observed and minimized after pooling a subgroup analysis. This latter analysis focused on biliary stricture, biliary leaks and stones, and vascular thrombosis and stenosis. Meta-analyses showed that patients receiving DCD organs have a greatly increased risk of biliary complications compared to those receiving DBD organs, particularly the following: biliary leaks and stones (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.22-2.34); and biliary stricture (OR = 1.58, 95% CI 1.21-2.06). DCD grafts tended to be but were not significantly associated with DBD regarding vascular thrombosis (OR = 1.62, 95% CI 1.05-2.50), and the risk of vascular stenosis in DCD grafts was not statistically significant (OR = 1.25, 95% CI, .70-2.25). CONCLUSION DCD was associated with an increased risk of biliary complications after LT, tended to indicate an increased risk of vascular thrombosis versus, and was not associated with an increased risk of vascular stenosis compared to DBD. There was no significant difference between the grafts.
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Affiliation(s)
- S Vivalda
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - H Zhengbin
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Y Xiong
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Z Liu
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Z Wang
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Q Ye
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China; Transplantation Medicine Engineering and Technology Research Center, National Health Commission, the 3rd Xiangya Hospital of Central South University, Changsha, China.
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17
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Jayant K, Reccia I, Virdis F, Shapiro AMJ. Systematic Review and Meta-Analysis on the Impact of Thrombolytic Therapy in Liver Transplantation Following Donation after Circulatory Death. J Clin Med 2018; 7:jcm7110425. [PMID: 30413051 PMCID: PMC6262573 DOI: 10.3390/jcm7110425] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 02/06/2023] Open
Abstract
Aim: The livers from DCD (donation after cardiac death) donations are often envisaged as a possible option to bridge the gap between the availability and increasing demand of organs for liver transplantation. However, DCD livers possess a heightened risk for complications and represent a formidable management challenge. The aim of this study was to evaluate the effects of thrombolytic flush in DCD liver transplantation. Methods: An extensive search of the literature database was made on MEDLINE, EMBASE, Cochrane, Crossref, Scopus databases, and clinical trial registry on 20 September 2018 to assess the role of thrombolytic tissue plasminogen activator (tPA) flush in DCD liver transplantation. Results: A total of four studies with 249 patients in the tPA group and 178 patients in the non-tPA group were included. The pooled data revealed a significant decrease in ischemic-type biliary lesions (ITBLs) (P = 0.04), re-transplantation rate (P = 0.0001), and no increased requirement of blood transfusion (P = 0.16) with a better one year graft survival (P = 0.02). Conclusions: To recapitulate, tPA in DCD liver transplantation decreased the incidence of ITBLs, re-transplantation and markedly improved 1-year graft survival, without any increased risk for blood transfusion, hence it has potential to expand the boundaries of DCD liver transplantation.
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Affiliation(s)
- Kumar Jayant
- Department of Surgery and Cancer, Imperial College London, London W12 OHS, UK.
| | - Isabella Reccia
- Department of Surgery and Cancer, Imperial College London, London W12 OHS, UK.
| | | | - A M James Shapiro
- Department of Surgery, University of Alberta, Edmonton, AB T6G 2B7, Canada.
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18
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Ghinolfi D, Tincani G, Rreka E, Roffi N, Coletti L, Balzano E, Catalano G, Meli S, Carrai P, Petruccelli S, Biancofiore G, Filipponi F, De Simone P. Dual aortic and portal perfusion at procurement prevents ischaemic-type biliary lesions in liver transplantation when using octogenarian donors: a retrospective cohort study. Transpl Int 2018; 32:193-205. [PMID: 30198069 DOI: 10.1111/tri.13342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/01/2018] [Accepted: 09/05/2018] [Indexed: 12/22/2022]
Abstract
Several risk factors for ischaemic-type biliary lesions (ITBL) after liver transplantation (LT) have been identified, but the role of portal vein perfusion at graft procurement is still unclear. This was a prospective study on double aortic and portal perfusion (DP) of liver grafts stratified by donor's decade (<60 yo; 60-69 yo; 70-79 yo and ≥80 yo) versus similar historical cohorts of primary, adult grafts procured with single aortic perfusion (SP) only. The primary study aim was to assess the role of DP on the incidence of ITBL. There was no difference in the incidence of overall biliary complications according to procurement technique for recipients of grafts <80 years. A higher incidence of ITBL was observed for patients receiving grafts ≥80 years and perfused through the aorta only (1.9 vs. 13.4%; P = 0.008). When analysing octogenarian grafts, donor male gender (HR = 6.4; P = 0.001), haemodynamic instability (HR = 4.9; P = 0.008), and type-2 diabetes mellitus (DM2) (HR = 3.0; P = 0.03) were all independent risk factors for ITBL, while double perfusion at procurement (HR = 0.1; P = 0.04) and longer donor intensive care unit (ICU) stay (HR = 0.7; P = 0.04) were protective factors. Dual aortic and portal perfusion has the potential to reduce post-transplant ITBL incidence for recipients of octogenarian donor grafts. Larger series are needed to confirm this preliminary experience.
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Affiliation(s)
- Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giovanni Tincani
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Erion Rreka
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Niccolo' Roffi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Laura Coletti
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Emanuele Balzano
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Gabriele Catalano
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Sonia Meli
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paola Carrai
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Stefania Petruccelli
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Gianni Biancofiore
- Anesthesia and Critical Care Medicine, University of Pisa Medical School Hospital, Pisa, Italy
| | - Franco Filipponi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
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19
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Mergental H, Stephenson BTF, Laing RW, Kirkham AJ, Neil DAH, Wallace LL, Boteon YL, Widmer J, Bhogal RH, Perera MTPR, Smith A, Reynolds GM, Yap C, Hübscher SG, Mirza DF, Afford SC. Development of Clinical Criteria for Functional Assessment to Predict Primary Nonfunction of High-Risk Livers Using Normothermic Machine Perfusion. Liver Transpl 2018; 24:1453-1469. [PMID: 30359490 PMCID: PMC6659387 DOI: 10.1002/lt.25291] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/06/2018] [Accepted: 05/03/2018] [Indexed: 12/12/2022]
Abstract
Increased use of high-risk allografts is critical to meet the demand for liver transplantation. We aimed to identify criteria predicting viability of organs, currently declined for clinical transplantation, using functional assessment during normothermic machine perfusion (NMP). Twelve discarded human livers were subjected to NMP following static cold storage. Livers were perfused with a packed red cell-based fluid at 37°C for 6 hours. Multilevel statistical models for repeated measures were employed to investigate the trend of perfusate blood gas profiles and vascular flow characteristics over time and the effect of lactate-clearing (LC) and non-lactate-clearing (non-LC) ability of the livers. The relationship of lactate clearance capability with bile production and histological and molecular findings were also examined. After 2 hours of perfusion, median lactate concentrations were 3.0 and 14.6 mmol/L in the LC and non-LC groups, respectively. LC livers produced more bile and maintained a stable perfusate pH and vascular flow >150 and 500 mL/minute through the hepatic artery and portal vein, respectively. Histology revealed discrepancies between subjectively discarded livers compared with objective findings. There were minimal morphological changes in the LC group, whereas non-LC livers often showed hepatocellular injury and reduced glycogen deposition. Adenosine triphosphate levels in the LC group increased compared with the non-LC livers. We propose composite viability criteria consisting of lactate clearance, pH maintenance, bile production, vascular flow patterns, and liver macroscopic appearance. These have been tested successfully in clinical transplantation. In conclusion, NMP allows an objective assessment of liver function that may reduce the risk and permit use of currently unused high-risk livers.
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Affiliation(s)
- Hynek Mergental
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham,Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Barnaby T. F. Stephenson
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
| | - Richard W. Laing
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham,Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Amanda J. Kirkham
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomics SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Desley A. H. Neil
- Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Lorraine L. Wallace
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
| | - Yuri L. Boteon
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham,Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Jeannette Widmer
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
| | - Ricky H. Bhogal
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham,Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - M. Thamara P. R. Perera
- Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Amanda Smith
- Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Gary M. Reynolds
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomics SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Stefan G. Hübscher
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
| | - Darius F. Mirza
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham,Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Simon C. Afford
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
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20
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A literature-based cost analysis of tissue plasminogen activator for prevention of biliary stricture in donation after circulatory death liver transplantation. Am J Surg 2018; 216:959-962. [PMID: 29724406 DOI: 10.1016/j.amjsurg.2018.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/02/2018] [Accepted: 04/11/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION This study sought to approximate the cost-effectiveness of tPA utilization for prevention of biliary strictures (PTBS) in donation after circulatory death liver transplantation (DCD-LT). METHODS Previously-reported PTBS rates in DCD-LT with and without tPA were used to calculate the number needed to treat (NNT) for prevention of one PTBS. The incremental cost of PTBS was then used to determine the cost effectiveness of tPA for prevention of PTBS. RESULTS The incidence of PTBS in the setting of tPA administration was 20%, while incidence in patients without tPA use was 43% (p < 0.001). Meta-analysis demonstrated a risk reduction of 15.7%, which translated into a NNT of 6.4. Cost associated with treating 6.4 patients was $50,353. Based on an incremental cost of $81,888 associated with PTBS management, use of tPA in DCD-LT protocols was estimated to save $31,528 per PTBS prevented. CONCLUSION Utilization of tPA in DCD-LT protocols represents one possible cost-effective strategy for prevention of PTBS in DCD-LT.
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21
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Schlegel A, Scalera I, Kalisvaart M, Muiesan P. Reply. Liver Transpl 2018; 24:563-564. [PMID: 28945956 DOI: 10.1002/lt.24949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/20/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom.,Liver Biomedical Research Unit, National Institute for Health Research, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Irene Scalera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Marit Kalisvaart
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom.,Liver Biomedical Research Unit, National Institute for Health Research, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom.,Department of Liver Surgery, Birmingham Children's Hospital, National Health Service Foundation Trust, Birmingham, United Kingdom
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22
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Detry O, Meurisse N, Honoré P. Impact of donor age in donation after circulatory death liver transplantation: Is the cutoff "60" still of relevance? Liver Transpl 2018; 24:562. [PMID: 28945953 DOI: 10.1002/lt.24951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 09/15/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Olivier Detry
- Department of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire Liege, University of Liege, Liege, Belgium
| | - Nicolas Meurisse
- Department of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire Liege, University of Liege, Liege, Belgium
| | - Pierre Honoré
- Department of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire Liege, University of Liege, Liege, Belgium
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23
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Foley DP. Avoid rejecting livers from donation after circulatory death donors based on donor age alone. Liver Transpl 2018; 24:325-326. [PMID: 29351370 DOI: 10.1002/lt.25018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/16/2018] [Indexed: 01/13/2023]
Affiliation(s)
- David P Foley
- Department of Surgery School of Medicine and Public Health, University of Wisconsin, Madison, WI
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24
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Ramirez P, Ferreras D, Febrero B, Royo M, Cascales P, Rodriguez J, Rios A, Fernandez J, González M, Sanchez-Bueno F, Robles R, Parrilla P. Outcomes of Liver Transplantation Using Older Donors After Circulatory Death and the Super-Rapid Technique: 14 Cases. Transplant Proc 2018; 50:601-604. [DOI: 10.1016/j.transproceed.2017.11.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 10/22/2017] [Accepted: 11/11/2017] [Indexed: 01/14/2023]
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25
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Reiling J, Forrest E, Bridle KR, Britton LJ, Santrampurwala N, Crawford DH, Dejong CH, Fawcett J. The Implications of the Shift Toward Donation After Circulatory Death in Australia. Transplant Direct 2017; 3:e226. [PMID: 29536027 PMCID: PMC5828691 DOI: 10.1097/txd.0000000000000743] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 09/08/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In recent years, an increasing number of donor livers are being declined for transplantation in Australia. The aim of this study was to evaluate the impact of donation after cardiac death and other factors associated with organ quality on liver utilization rates in Australia. METHODS Data on organ donors who donated at least 1 organ between 2005 and 2014 were obtained from the Australia and New Zealand organ donation registry. Temporal changes in donor characteristics were assessed and a logistical regression analysis was performed to evaluate their association with liver nonuse. RESULTS The number of organ donors increased from 175 in 2005 to 344 in 2014, with overall 19% being donation after cardiac death donors (P < 0.001). The percentage of livers deemed unsuitable for transplantation increased from 24% in 2005 to 41% in 2014 (P < 0.001). Donation after cardiac death was identified as the most important risk factor for nonuse with an odds ratio of 25.88 (95% confidence interval, 18.84-35.56), P < 0.001) followed by donor age, obesity, and diabetes. DISCUSSION This study shows that livers donated after circulatory death are an underused resource in Australia. Better use of these currently available organs would be a highly cost-effective way of reducing waiting list mortality in liver transplantation.
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Affiliation(s)
- Janske Reiling
- Faculty of Medicine, the University of Queensland, Brisbane, Australia
- Australian and New Zealand Organ Donation, Adelaide, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
- Department of Surgery, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Elizabeth Forrest
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Australia
| | | | - Laurence J. Britton
- Faculty of Medicine, the University of Queensland, Brisbane, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | - Nishreen Santrampurwala
- Faculty of Medicine, the University of Queensland, Brisbane, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | - Darrell H.G. Crawford
- Faculty of Medicine, the University of Queensland, Brisbane, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | - Cornelis H.C. Dejong
- Department of Surgery, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, RWTH Universitätsklinikum Aachen, Aachen, Germany
| | - Jonathan Fawcett
- Faculty of Medicine, the University of Queensland, Brisbane, Australia
- Department of Surgery, RWTH Universitätsklinikum Aachen, Aachen, Germany
- PA Research Foundation, Princess Alexandra Hospital, Brisbane, Australia
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26
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Hobeika MJ, Miller CM, Pruett TL, Gifford KA, Locke JE, Cameron AM, Englesbe MJ, Kuhr CS, Magliocca JF, McCune KR, Mekeel KL, Pelletier SJ, Singer AL, Segev DL. PROviding Better ACcess To ORgans: A comprehensive overview of organ-access initiatives from the ASTS PROACTOR Task Force. Am J Transplant 2017; 17:2546-2558. [PMID: 28742951 DOI: 10.1111/ajt.14441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/25/2017] [Accepted: 07/13/2017] [Indexed: 01/25/2023]
Abstract
The American Society of Transplant Surgeons (ASTS) PROviding better Access To Organs (PROACTOR) Task Force was created to inform ongoing ASTS organ access efforts. Task force members were charged with comprehensively cataloguing current organ access activities and organizing them according to stakeholder type. This white paper summarizes the task force findings and makes recommendations for future ASTS organ access initiatives.
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Affiliation(s)
- M J Hobeika
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - C M Miller
- Liver Transplantation Program, Cleveland Clinic, Cleveland, OH, USA
| | - T L Pruett
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - K A Gifford
- American Society of Transplant Surgeons, Arlington, VA, USA
| | - J E Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - A M Cameron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M J Englesbe
- Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, MI, USA
| | - C S Kuhr
- Virginia Mason Medical Center, Seattle, WA, USA
| | - J F Magliocca
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - K R McCune
- Department of Surgery, Columbia University, New York, NY, USA
| | - K L Mekeel
- Division of Transplantation and Hepatobiliary Surgery, University of California San Diego, San Diego, CA, USA
| | - S J Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - A L Singer
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA
| | - D L Segev
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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27
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Infusion of mesenchymal stromal cells after deceased liver transplantation: A phase I-II, open-label, clinical study. J Hepatol 2017; 67:47-55. [PMID: 28284916 DOI: 10.1016/j.jhep.2017.03.001] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 02/24/2017] [Accepted: 03/01/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Mesenchymal stromal cell (MSC) infusion could be a means to establish tolerance in solid organ recipients. The aim of this prospective, controlled, phase I study was to evaluate the feasibility, safety and tolerability of a single infusion of MSCs in liver transplant recipients. METHODS Ten liver transplant recipients under standard immunosuppression received 1.5-3×106/kg third-party unrelated MSCs on postoperative day 3±2, and were prospectively compared to a control group of ten liver transplant recipients. As primary endpoints, MSC infusion toxicity was evaluated, and infectious and cancerous complications were prospectively recorded until month 12 in both groups. As secondary endpoints, rejection rate, month-6 graft biopsies, and peripheral blood lymphocyte phenotyping were compared. Progressive immunosuppression weaning was attempted from month 6 to 12 in MSC recipients. RESULTS No variation in vital parameters or cytokine release syndrome could be detected during and after MSC infusion. No patient developed impairment of organ functions (including liver graft function) following MSC infusion. No increased rate of opportunistic infection or de novo cancer was detected. As secondary endpoints, there was no difference in overall rates of rejection or graft survival. Month-6 biopsies did not demonstrate a difference between groups in the evaluation of rejection according to the Banff criteria, in the fibrosis score or in immunohistochemistry (including Tregs). No difference in peripheral blood lymphocyte typing could be detected. The immunosuppression weaning in MSC recipients was not successful. CONCLUSIONS No side effect of MSC infusion at day 3 after liver transplant could be detected, but this infusion did not promote tolerance. This study opens the way for further MSC or Treg-based trials in liver transplant recipients. LAY SUMMARY Therapy with mesenchymal stromal cells (MSCs) has been proposed as a means to improve results of solid organ transplantation. One of the potential MSC role could be to induce tolerance after liver transplantation, i.e. allowing the cessation of several medications with severe side effects. This study is the first-in-man use of MSC therapy in ten liver transplant recipients. This study did not show toxicity after a single MSC infusion but it was not sufficient to allow withdrawal of immunosuppression. CLINICAL TRIAL REGISTRATION NUMBER Eudract: # 2011-001822-81, ClinicalTrials.gov: # NCT 01429038.
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28
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Mergental H, Perera MTPR, Laing RW, Muiesan P, Isaac JR, Smith A, Stephenson BTF, Cilliers H, Neil DAH, Hübscher SG, Afford SC, Mirza DF. Transplantation of Declined Liver Allografts Following Normothermic Ex-Situ Evaluation. Am J Transplant 2016; 16:3235-3245. [PMID: 27192971 DOI: 10.1111/ajt.13875] [Citation(s) in RCA: 227] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/28/2016] [Accepted: 04/28/2016] [Indexed: 01/25/2023]
Abstract
The demand for liver transplantation (LT) exceeds supply, with rising waiting list mortality. Utilization of high-risk organs is low and a substantial number of procured livers are discarded. We report the first series of five transplants with rejected livers following viability assessment by normothermic machine perfusion of the liver (NMP-L). The evaluation protocol consisted of perfusate lactate, bile production, vascular flows, and liver appearance. All livers were exposed to a variable period of static cold storage prior to commencing NMP-L. Four organs were recovered from donors after circulatory death and rejected due to prolonged donor warm ischemic times; one liver from a brain-death donor was declined for high liver function tests (LFTs). The median (range) total graft preservation time was 798 (range 724-951) min. The transplant procedure was uneventful in every recipient, with immediate function in all grafts. The median in-hospital stay was 10 (range 6-14) days. At present, all recipients are well, with normalized LFTs at median follow-up of 7 (range 6-19) months. Viability assessment of high-risk grafts using NMP-L provides specific information on liver function and can permit their transplantation while minimizing the recipient risk of primary graft nonfunction. This novel approach may increase organ availability for LT.
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Affiliation(s)
- H Mergental
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, Institute of Immunology and Immunotherapy, Institute for Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - M T P R Perera
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R W Laing
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, Institute of Immunology and Immunotherapy, Institute for Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - P Muiesan
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J R Isaac
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Smith
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - B T F Stephenson
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, Institute of Immunology and Immunotherapy, Institute for Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - H Cilliers
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D A H Neil
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S G Hübscher
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S C Afford
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, Institute of Immunology and Immunotherapy, Institute for Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - D F Mirza
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. .,National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, Institute of Immunology and Immunotherapy, Institute for Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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29
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Scalea JR, Redfield RR, Foley DP. Liver transplant outcomes using ideal donation after circulatory death livers are superior to using older donation after brain death donor livers. Liver Transpl 2016; 22:1197-204. [PMID: 27314220 DOI: 10.1002/lt.24494] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 06/03/2016] [Indexed: 02/06/2023]
Abstract
Multiple reports have demonstrated that liver transplantation following donation after circulatory death (DCD) is associated with poorer outcomes when compared with liver transplantation from donation after brain death (DBD) donors. We hypothesized that carefully selected, underutilized DCD livers recovered from younger donors have excellent outcomes. We performed a retrospective study of the United Network for Organ Sharing database to determine graft survivals for patients who received liver transplants from DBD donors of age ≥ 60 years, DBD donors < 60 years, and DCD donors < 50 years of age. Between January 2002 and December 2014, 52,271 liver transplants were performed in the United States. Of these, 41,181 (78.8%) underwent transplantation with livers from DBD donors of age < 60 years, 8905 (17.0%) from DBD donors ≥ 60 years old, and 2195 (4.2%) livers from DCD donors < 50 years of age. DCD livers of age < 50 years with < 6 hours of cold ischemia time (CIT) had superior graft survival when compared with DBD livers ≥ age 60 years (P < 0.001). In 2014, there were 133 discarded DCD livers; of these, 111 (83.4%) were from donors < age 50 years old. Young DCD donor livers (age < 50 years old) with short CITs yield results better than that seen with DBD livers > 60 years old. Careful donor organ and recipient selection can lead to excellent results, despite previous reports suggesting otherwise. Increased acceptance of these DCD livers would lead to shorter wait list times and increased national liver transplant rates. Liver Transplantation 22 1197-1204 2016 AASLD.
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; and
| | - Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; and
| | - David P Foley
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; and.,Veterans Administration Surgical Services, William S. Middleton Memorial Veterans Hospital, Madison, WI
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30
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Blok JJ, Detry O, Putter H, Rogiers X, Porte RJ, van Hoek B, Pirenne J, Metselaar HJ, Lerut JP, Ysebaert DK, Lucidi V, Troisi RI, Samuel U, den Dulk AC, Ringers J, Braat AE. Longterm results of liver transplantation from donation after circulatory death. Liver Transpl 2016; 22:1107-14. [PMID: 27028896 DOI: 10.1002/lt.24449] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/05/2016] [Accepted: 03/09/2016] [Indexed: 12/13/2022]
Abstract
Donation after circulatory death (DCD) liver transplantation (LT) may imply a risk for decreased graft survival, caused by posttransplantation complications such as primary nonfunction or ischemic-type biliary lesions. However, similar survival rates for DCD and donation after brain death (DBD) LT have been reported. The objective of this study is to determine the longterm outcome of DCD LT in the Eurotransplant region corrected for the Eurotransplant donor risk index (ET-DRI). Transplants performed in Belgium and the Netherlands (January 1, 2003 to December 31, 2007) in adult recipients were included. Graft failure was defined as either the date of recipient death or retransplantation whichever occurred first (death-uncensored graft survival). Mean follow-up was 7.2 years. In total, 126 DCD and 1264 DBD LTs were performed. Kaplan-Meier survival analyses showed different graft survival for DBD and DCD at 1 year (77.7% versus 74.8%, respectively; P = 0.71), 5 years (65.6% versus 54.4%, respectively; P = 0.02), and 10 years (47.3% versus 44.2%, respectively; P = 0.55; log-rank P = 0.038). Although there was an overall significant difference, the survival curves almost reach each other after 10 years, which is most likely caused by other risk factors being less in DCD livers. Patient survival was not significantly different (P = 0.59). Multivariate Cox regression analysis showed a hazard ratio of 1.7 (P < 0.001) for DCD (corrected for ET-DRI and recipient factors). First warm ischemia time (WIT), which is the time from the end of circulation until aortic cold perfusion, over 25 minutes was associated with a lower graft survival in univariate analysis of all DCD transplants (P = 0.002). In conclusion, DCD LT has an increased risk for diminished graft survival compared to DBD. There was no significant difference in patient survival. DCD allografts with a first WIT > 25 minutes have an increased risk for a decrease in graft survival. Liver Transplantation 22 1107-1114 2016 AASLD.
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Affiliation(s)
- Joris J Blok
- Department of Surgery, Division of Transplantation, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, University Hospital of Liège, Liège, Belgium
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Xavier Rogiers
- Department of Surgery, Ghent University Hospital Medical School, Ghent, Belgium
| | - Robert J Porte
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jan P Lerut
- Starzl Unit of Abdominal Transplantation, Department of Abdominal Surgery and Transplantation, University Hospitals Saint Luc, Brussels, Belgium
| | - Dirk K Ysebaert
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp University, Belgium
| | - Valerio Lucidi
- Department of Abdominal Surgery, Hepatobiliary and Liver Transplantation Unit, Erasme Hospital ULB, Brussels, Belgium
| | - Roberto I Troisi
- Department of Surgery, Ghent University Hospital Medical School, Ghent, Belgium
| | - Undine Samuel
- Eurotransplant International Foundation, Leiden, the Netherlands
| | - A Claire den Dulk
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Jan Ringers
- Department of Surgery, Division of Transplantation, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
| | - Andries E Braat
- Department of Surgery, Division of Transplantation, Leiden University Medical Center, Leiden University, Leiden, the Netherlands
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31
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Optimization of Perioperative Conditions to Prevent Ischemic Cholangiopathy in Donation After Circulatory Death Donor Liver Transplantation. Transplantation 2016; 100:1699-704. [DOI: 10.1097/tp.0000000000001204] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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32
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Hessheimer AJ, Cárdenas A, García-Valdecasas JC, Fondevila C. Can we prevent ischemic-type biliary lesions in donation after circulatory determination of death liver transplantation? Liver Transpl 2016; 22:1025-33. [PMID: 27082839 DOI: 10.1002/lt.24460] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/02/2016] [Indexed: 12/23/2022]
Abstract
The pool of livers for transplantation consists of an increasingly greater proportion of marginal grafts, in particular those arising through donation after circulatory determination of death (DCD). However, a primary factor limiting the use of marginal livers, and, thereby, the applicability of liver transplantation in general, is concern over the subsequent development of ischemic-type biliary lesion (ITBL). ITBL is a devastating complication of liver transplantation; in its most severe forms, recipients suffer frequent infectious complications that require repeated invasive biliary procedures and ultimately result in either retransplantation or death. In the present review article, we discuss our current understanding of ITBL pathogenesis as it pertains to DCD, in particular. We discuss the most relevant theories regarding its development and provide a comprehensive overview of the most promising strategies we have available today to prevent the appearance of ITBL, strategies that may, furthermore, allow us to transplant a greater proportion of marginal livers in the future. Liver Transplantation 22 1025-1033 2016 AASLD.
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Affiliation(s)
- Amelia J Hessheimer
- General and Digestive Surgery and, University of Barcelona, Barcelona, Spain
| | - Andrés Cárdenas
- Gastrointestinal/Liver Unit, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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33
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Tu Z, Xiang P, Xu X, Zhou L, Zhuang L, Wu J, Wang W, Zheng S. DCD liver transplant infection: experience from a single centre in China. Int J Clin Pract 2016; 70 Suppl 185:3-10. [PMID: 27197998 DOI: 10.1111/ijcp.12810] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIM The purpose of our study was to evaluate the incidence, timing, location and risk factors for bacterial and fungal infections after donation after cardiac death (DCD) liver transplant and clearly delineate any relationship between infection and survival in DCD liver transplant recipients. METHODS We retrospectively reviewed 257 consecutive patients undergoing DCD liver transplant between October 2010 and May 2015 at our centre. RESULTS A total of 133 patients (51.8%) developed at least one bacterial or fungal infection episode. The predominant infection site was the respiratory tract, followed by the blood stream. Most of the infections occurred within the first week after liver transplant (61.9%). A recipient respiratory support time greater than 7 days (p = 0.041), post-transplant hospital time greater than 24 days (p = 0.002) and renal failure after DCD liver transplant (p = 0.039) were independent predictors of bacterial and fungal infection. The area under the receiver operating characteristic (ROC) curve (AUC) of the transplant infection risk assessment model was 0.788. The 1- and 3-year survival rates for recipients without infection were significantly increased compared with recipients with infection (96.1% and 89.0% vs. 81.5% and 75.9%, p = 0.007). CONCLUSION This is the first study that offers detailed data revealing the timing and incidence of bacterial and fungal infection among adult DCD liver transplant recipients. Bacterial and fungal infection occurs at a high rate during the first week after DCD liver transplant, especially in patients with prolonged respiratory support time and renal failure, and infection is related to increased hospital stay.
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Affiliation(s)
- Z Tu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou, China
| | - P Xiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou, China
| | - X Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou, China
| | - L Zhou
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou, China
| | - L Zhuang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou, China
| | - J Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou, China
| | - W Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou, China
| | - S Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Collaborative Innovation Center for Diagnosis Treatment of Infectious Diseases, Hangzhou, China
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34
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Detry O. Should ABO-incompatible deceased liver transplantation be reconsidered? Transpl Int 2016; 28:788-9. [PMID: 25847352 DOI: 10.1111/tri.12573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 03/31/2015] [Indexed: 12/15/2022]
Affiliation(s)
- Olivier Detry
- Department of Abdominal Surgery and Transplantation, CHU Liege, University of Liege, Liege, Belgium
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35
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Sutherland AI, IJzermans JNM, Forsythe JLR, Dor FJMF. Kidney and liver transplantation in the elderly. Br J Surg 2015; 103:e62-72. [PMID: 26662845 DOI: 10.1002/bjs.10064] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 10/27/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transplant surgery is facing a shortage of deceased donor organs. In response, the criteria for organ donation have been extended, and an increasing number of organs from older donors are being used. For recipients, the benefits of transplantation are great, and the growing ageing population has led to increasing numbers of elderly patients being accepted for transplantation. METHODS The literature was reviewed to investigate the impact of age of donors and recipients in abdominal organ transplantation, and to highlight aspects of the fine balance in donor and recipient selection and screening, as well as allocation policies fair to young and old alike. RESULTS Overall, kidney and liver transplantation from older deceased donors have good outcomes, but are not as good as those from younger donors. Careful donor selection based on risk indices, and potentially biomarkers, special allocation schemes to match elderly donors with elderly recipients, and vigorous recipient selection, allows good outcomes with increasing age of both donors and recipients. The results of live kidney donation have been excellent for donor and recipient, and there is a trend towards inclusion of older donors. Future strategies, including personalized immunosuppression for older recipients as well as machine preservation and reconditioning of donor organs, are promising ways to improve the outcome of transplantation between older donors and older recipients. CONCLUSION Kidney and liver transplantation in the elderly is a clinical reality. Outcomes are good, but can be optimized by using strategies that modify donor risk factors and recipient co-morbidities, and personalized approaches to organ allocation and immunosuppression.
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Affiliation(s)
- A I Sutherland
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - J N M IJzermans
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J L R Forsythe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - F J M F Dor
- Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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36
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Firl DJ, Hashimoto K, O'Rourke C, Diago-Uso T, Fujiki M, Aucejo FN, Quintini C, Kelly DM, Miller CM, Fung JJ, Eghtesad B. Impact of donor age in liver transplantation from donation after circulatory death donors: A decade of experience at Cleveland Clinic. Liver Transpl 2015; 21:1494-503. [PMID: 26334196 DOI: 10.1002/lt.24316] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/23/2015] [Accepted: 08/12/2015] [Indexed: 12/12/2022]
Abstract
The use of liver grafts from donation after circulatory death (DCD) donors remains controversial, particularly with donors of advanced age. This retrospective study investigated the impact of donor age in DCD liver transplantation. We examined 92 recipients who received DCD grafts and 92 matched recipients who received donation after brain death (DBD) grafts at Cleveland Clinic from January 2005 to June 2014. DCD grafts met stringent criteria to minimize risk factors in both donors and recipients. The 1-, 3-, and 5-year graft survival in DCD recipients was significantly inferior to that in DBD recipients (82%, 71%, 66% versus 92%, 87%, 85%, respectively; P = 0.03). Six DCD recipients (7%), but no DBD recipients, experienced ischemic-type biliary stricture (P = 0.01). However, the incidence of biliary stricture was not associated with donor age (P = 0.57). Interestingly, recipients receiving DCD grafts from donors who were <45 years of age (n = 55) showed similar graft survival rates compared to those receiving DCD grafts from donors who were ≥45 years of age (n = 37; 80%, 69%, 66% versus 83%, 72%, 66%, respectively; P = 0.67). Cox proportional hazards modeling in all study populations (n = 184) revealed advanced donor age (P = 0.05) and the use of a DCD graft (P = 0.03) as unfavorable factors for graft survival. Logistic regression analysis showed that the risk of DBD graft failure increased with increasing age, but the risk of DCD graft failure did not increase with increasing age (P = 0.13). In conclusion, these data suggest that stringent donor and recipient selection may ameliorate the negative impact of donor age in DCD liver transplantation. DCD grafts should not be discarded because of donor age, per se, and could help expand the donor pool for liver transplantation.
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Affiliation(s)
- Daniel J Firl
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Koji Hashimoto
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Colin O'Rourke
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago-Uso
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Masato Fujiki
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Federico N Aucejo
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Cristiano Quintini
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Dympna M Kelly
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Charles M Miller
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - John J Fung
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
| | - Bijan Eghtesad
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH.,Department of General Surgery, Digestive Disease Institute, Cleveland, OH
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37
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Detry O. Donor Age in Liver Transplantation: Donation after Circulatory Death. J Am Coll Surg 2015; 221:779. [PMID: 26296683 DOI: 10.1016/j.jamcollsurg.2015.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 06/01/2015] [Indexed: 11/24/2022]
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38
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O'Neill S, Roebuck A, Khoo E, Wigmore SJ, Harrison EM. A meta-analysis and meta-regression of outcomes including biliary complications in donation after cardiac death liver transplantation. Transpl Int 2015; 27:1159-74. [PMID: 25052036 DOI: 10.1111/tri.12403] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/05/2014] [Accepted: 07/12/2014] [Indexed: 12/11/2022]
Abstract
Donation after cardiac death (DCD) liver transplantation is increasingly common but concerns exist over the development of biliary complications and ischemic cholangiopathy (IC). This study aimed to compare outcomes between DCD and donation after brain death (DBD) liver grafts. Studies reporting on post-transplantation outcomes after Maastricht category III DCD liver transplantation were screened for inclusion. Odds ratios (OR) with 95% confidence intervals were produced using random-effects models for the incidence of biliary complications, IC, graft and recipient survival. Meta-regression was undertaken to identify between-study predictors of effect size for biliary complications and IC. PROSPERO Record: CRD42012002113. Twenty-five studies with 62 184 liver transplant recipients (DCD = 2478 and DBD = 59 706) were included. In comparison with DBD, there was a significant increase in biliary complications [OR = 2.4 (1.9, 3.1); P < 0.00001] and IC [OR = 10.5 (5.7, 19.5); P < 0.00001] following DCD liver transplantation. In comparison with DBD, at 1 year [OR = 0.7 (0.5, 0.8); P = 0.0002] and 3 years [OR = 0.6 (0.5, 0.8); P = 0.001], there was a significant decrease in graft survival following DCD liver transplantation. At 1 year, there was also a nonsignificant decrease [OR = 0.8 (0.6, 1.0); P = 0.08] and by 3 years a significant decrease [OR = 0.7 (0.5, 1.0); P = 0.04] found in recipient survival following DCD liver transplantation. Eleven factors were entered into meta-regression models, but none explained the variability in effect size between studies. DCD liver transplantation is associated with an increase in biliary complications, IC, graft loss and mortality. Significant unexplained differences in effect size exist between centers.
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Affiliation(s)
- Stephen O'Neill
- MRC Centre for Inflammation Research, Tissue Injury and Repair Group, University of Edinburgh, Edinburgh, UK
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39
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Detry O, Govaerts L, Deroover A, Vandermeulen M, Meurisse N, Malenga S, Bletard N, Mbendi C, Lamproye A, Honoré P, Meunier P, Delwaide J, Hustinx R. Prognostic value of 18F-FDG PET/CT in liver transplantation for hepatocarcinoma. World J Gastroenterol 2015; 21:3049-3054. [PMID: 25780305 PMCID: PMC4356927 DOI: 10.3748/wjg.v21.i10.3049] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 08/29/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the prognostic value of pretreatment FDG positron emission tomography computed tomography (PET-CT) in patients with hepatocarcinoma treated by liver transplantation (LT).
METHODS: The authors retrospectively analyzed the data of 27 patients (mean age 58 ± 9 years) who underwent FDG PET-CT before LT for hepatocarcinoma. Mean follow-up was 26 ± 18 mo. The FDG PET/CT was performed according to a standard clinical protocol: 4 MBqFDG/kg body weight, uptake 60 min, low-dose non-enhanced CT. The authors measured the SUVmax and SUVmean of the tumor and the normal liver. The tumor/liver activity ratios (RSUVmax and RSUVmean) were tested as prognostic factors and compared to the following conventional prognostic factors: MILAN, CLIP, OKUDA, TNM stage, alphafoetoprotein level, portal thrombosis, size of the largest nodule, tumor differentiation, microvascular invasion, underlying cirrhosis and liver function.
RESULTS: Overall and recurrence free survivals were 80.7% and 67.4% at 3 years, and 70.6% and 67.4% at 5 years, respectively. According to a multivariate Cox model, only FDG PET/CT RSUVmax predicted recurrence free survival. Even though the MILAN criteria alone were not predictive, it is worth noting that none of the patients outside the MILAN criteria and with RSUVmax < 1.15 relapsed.
CONCLUSION: FDG PET/CT with an RSUVmax cut-off value of 1.15 is a strong prognostic factor for recurrence and death in patients with HCC treated by LT in this retrospective series. Further prospective studies should test whether this metabolic index should be systematically included in the preoperative assessment.
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40
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den Dulk AC, Sebib Korkmaz K, de Rooij BJF, Sutton ME, Braat AE, Inderson A, Dubbeld J, Verspaget HW, Porte RJ, van Hoek B. High peak alanine aminotransferase determines extra risk for nonanastomotic biliary strictures after liver transplantation with donation after circulatory death. Transpl Int 2015; 28:492-501. [PMID: 25601020 DOI: 10.1111/tri.12524] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 09/21/2014] [Accepted: 01/11/2015] [Indexed: 12/11/2022]
Abstract
Orthotopic liver transplantation (OLT) with donation after circulatory death (DCD) often leads to a higher first week peak alanine aminotransferase (ALT) and a higher rate of biliary nonanastomotic strictures (NAS) as compared to donation after brain death (DBD). This retrospective study was to evaluate whether an association exists between peak ALT and the development of NAS in OLT with livers from DBD (n = 399) or DCD (n = 97) from two transplantation centers. Optimal cutoff value of peak ALT for risk of development of NAS post-DCD-OLT was 1300 IU/l. The 4-year cumulative incidence of NAS after DCD-OLT was 49.5% in patients with a high ALT peak post-OLT, compared with 11.3% in patients with a low ALT peak. (P < 0.001). No relation between peak ALT and NAS was observed after DBD-OLT. Multivariate analysis revealed peak ALT ≥1300 IU/l [adjusted hazard ratio (aHR) = 3.71, confidence interval (CI) (1.26-10.91)] and donor age [aHR = 1.04, CI 1.00-1.07] to be independently associated with development of NAS post-DCD-OLT. A peak ALT of <1300 IU/l carries a risk for NAS similar to DBD-OLT. Thus, in DCD-OLT, but not in DBD-OLT, peak ALT discriminates patients at high or low risk for NAS.
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Affiliation(s)
- A Claire den Dulk
- Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
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41
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Dutkowski P, Clavien PA. Solutions to shortage of liver grafts for transplantation. Br J Surg 2014; 101:739-41. [PMID: 24817650 DOI: 10.1002/bjs.9540] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Increasing the donor supply
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Affiliation(s)
- P Dutkowski
- Swiss Hepatopancreatobiliary and Transplantation Centre, Department of Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
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